Diagnostic dilemma: Syncope vs. seizure

Shattering assumptions with a case study roundup


This article originally appeared in the August 2021 EMS1 Editor's Picks newsletterClick here to subscribe.

I’ve been thinking and teaching lately about the diagnostic dilemma posed between syncope and seizure. These two presentations can be impossible to sort in the prehospital setting. As for syncope, my feeling is that emergency providers often pigeonhole all young folks who pass out very conveniently into the “vasovagal” diagnostic category.  

Here, I’ll share some resources that are not directed toward standard textbook teaching. 

Are you guilty?

An ECG is vital in all patients who lose consciousness, and we must view young syncope ECGs through non-ischemia lenses and not just comment on ST elevation.
An ECG is vital in all patients who lose consciousness, and we must view young syncope ECGs through non-ischemia lenses and not just comment on ST elevation. (Irina S, MD (@irinasanj)/Twitter)

In a recent "Neurology" article, Nightscales, et. al., investigated the epidemiology and mortality in psychogenic, non-epileptic events. In my career, I know that I have certainly been guilty of underselling and underestimating these patients. This publication was a needed reminder that psychogenic non-epileptic seizure patients have significant morbidity and mortality, and need prompt care and compassion in the emergency setting.

Failure to pace

This presentation by Tarlan Hedayati, MD, is a reminder that patients can lose consciousness if their cardiac devices fail. Pacemaker pathology is often overwhelming, and this is the most logical and coherent summary of an emergent approach to these devices I’ve ever heard/seen.

Check your lens

An ECG is vital in all patients who lose consciousness, no matter how young. Ultrasound Fellow Irina S, MD, shared this photo from a patient who presented with a “seizure.” There is no 12-lead, just a monitor photo, which clearly demonstrates a Brugada pattern in V1. More information is needed, but this is an excellent reminder that we must view young syncope ECGs through non-ischemia lenses and not just comment on ST elevation.

A broad spectrum of symptomatology

In this Life in the Fast Lane ECG Case, shared by Robert Buttner and Emre Aslanger, a 24-year-old female presents who “passed out” after alcohol ingestion. We see this presentation on every single shift. However, look more closely at the ECG; this patient is much more than “just intoxicated.”

Shattering assumptions: ‘Pseudoseizures’

Kevin Crocker joins me in this episode of The MCHD Paramedic Podcast to discuss psychogenic seizures, a debilitating disease that needs more attention and improved treatment options. Listen to have your prior assumptions shattered, and leave a better and more empathetic provider.

Life, death and medicine

Finally, unrelated to syncope and seizure, this recent “Stimulus” podcast with Rob Orman, MD, will hopefully make you step back a bit from all the current pandemic stressors and appreciate what a gift it is to be able to care for our patients.

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